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Subcutaneous Ozone Injection Protocol
Concentration, volume per site, session limits and the hand (glove) technique for subcutaneous ozone injection.
Quick answer: Subcutaneous ozone injection per Madrid uses 5–10 µg/mL and 1–2 mL per site. MediSkill limit: 20 mL per session (Madrid allows up to 100 mL). The glove technique was given twice a week for about 6 sessions.
Warning
Requires hands-on training from an experienced physician
Subcutaneous ozone injection should only be performed by a practitioner trained in it by an experienced physician.
Practitioner-only procedure. Injecting ozone under the skin is done by trained, licensed clinicians. This sheet is a reference for them. It is not a self-treatment guide and not medical advice. Strict sterile technique is required every time.
What are the basics of subcutaneous ozone injection?
- Subcutaneous injection places ozone-oxygen gas in the fat layer just under the skin, at several sites over a painful area. This sheet covers the general method and the glove technique for the hands.
- Madrid also uses subcutaneous ozone for cellulite, with its own volumes, concentration and schedule. This sheet does not cover it. The MediSkill limit of 20 mL per session applies.
- Madrid's Table 1A for general subcutaneous use lists 5 (low), 8 (medium) and 10 (high) µg/mL at 1 to 2 mL a site, which is 5 to 20 µg per site. Madrid allows up to 100 mL in one session. MediSkill limit: 20 mL per session.
- The glove technique (subcutaneous emphysema technique, designed by Dr. Adriana Schwartz) fills the tissue under the skin on the back of the hand with gas. Madrid describes it for neuropathic pain and osteoarthritis of the hand. The ISCO3 method sheet adds De Quervain's tenosynovitis, thumb-base arthritis and tendinitis.
- Madrid's own sources disagree on the glove volume: the text of section 4.9 says 10 to 20 mL at 5 to 20 µg/mL, while Table 1A and the ISCO3 method sheet say 10 to 40 mL. Both are shown below. MediSkill limit: 20 mL per session, so the glove technique stays at 20 mL or less.
Sources: Madrid Declaration on Ozone Therapy, 4th edition (ISCO3, 2025), Table 1A and sections 4.9 and 6.1; the ISCO3 glove technique method sheet (MET/00/17). Paraphrased.
What dose and technique are used for subcutaneous ozone injection?
Two procedures share this route and are shown side by side.
| General subcutaneous (Madrid) | Glove technique, hands (Madrid, ISCO3) | |
|---|---|---|
| Concentration | 5, 8 or 10 µg/mL. | 5 to 20 µg/mL. The method sheet says to start at 5 to 8 µg/mL and increase a little each session. |
| Volume | 1 to 2 mL per site. MediSkill limit: 20 mL per session (Madrid allows up to 100 mL). | 10 to 20 mL (section 4.9). 10 to 40 mL (Table 1A and method sheet). MediSkill limit: 20 mL per session. |
| Dose | 5 to 10, 8 to 16 or 10 to 20 µg per site. | 50 to 80, 100 to 400 or 200 to 800 µg (Table 1A, low, medium, high). |
| Needle | Not stated for the general method (27G in Madrid's cellulite section). | 30G, 13 mm (½ inch), on a 20 mL syringe. |
| Technique | Several sites over the painful area, spaced apart. | Pinch the skin on the back of the hand with two fingers, insert the needle and infiltrate very slowly toward the fingers. |
| Schedule | Not stated for the general method. A trial used every other day for 10 procedures. | Twice a week, or until the pain is gone (about 6 sessions). |
Madrid's titration rule applies: start low and increase gradually.
What are the best tips when using subcutaneous ozone injection?
- For the hand, rest the patient's hands on a cushion and clean the skin with an antiseptic first.
- Inject slowly. If it hurts, slow down further (ISCO3 method sheet).
- After the glove technique, the method sheet suggests massaging the area with ozonated oil at 600 peroxide index. Madrid's cellulite section finishes with 400 to 600.
- The ISCO3 glove method sheet (and Madrid's 3rd edition, for cellulite) suggests pairing the local injections with a systemic ozone method, such as major autohemotherapy or rectal insufflation.
- Expect pain, warmth, burning or heaviness during the injection, and redness, goose bumps or a visible gas pocket under the skin afterward (a congress abstract by Roditi Herrera, 2019, describes this).
- In the one glove-technique case report, the injection itself was very painful (9 out of 10) for a few seconds.
- Frequent side effects in the method sheet are local pain and bruising. Check the patient once a week.
What are the precautions for subcutaneous ozone injection, and who should avoid it?
- Never breathe ozone gas. Keep the room ventilated.
- Sterile technique every time. Madrid says most serious side effects trace back to malpractice, including technique, asepsis and antisepsis. Its reported serious events include septic arthritis of the knee after intra-articular infiltration and abscess after paravertebral injection. It also reports one death from sepsis after a paravertebral infiltration done without proper asepsis (Madrid Declaration on Ozone Therapy, 4th edition (ISCO3, 2025), section 2.5).
- Clean the skin with an antiseptic and let it dry before the needle goes through. Use sterile, single-use needles and syringes, and ozone-resistant syringes for the gas.
- Check with your licensing board that this procedure, and anything you inject along with the ozone, is within your scope of practice.
- Never inject ozone gas into a vein or an artery. Madrid strongly discourages both because of the risk of air embolism, and lists embolic events after paravertebral and intradiscal injections among its serious adverse events.
- The glove technique is not for a patient with a septic joint, a high fever or who cannot cooperate actively (ISCO3 method sheet).
- Madrid's cellulite section says never to inject below the knee because of the risk of air embolism. It gives no separate rule for the general method, so this sheet follows the stricter one for larger volumes on the legs.
- Two published case reports describe reversible brain effects after subcutaneous ozone: encephalopathy after an injection at facial acupuncture points (2025), and reversible posterior leukoencephalopathy (temporary swelling of the brain's white matter) after injections in the neck and upper trunk (Kamiyama 2005). Both patients recovered. Use small volumes and low concentrations, and avoid the face and neck for general subcutaneous work.
- Do not exceed 20 mL in one session (MediSkill limit; Madrid allows up to 100 mL, and 200 mL for cellulite).
Contraindications
The Madrid Declaration lists these contraindications for systemic ozone (IV and blood). It gives no separate list for subcutaneous injection, but many practitioners use the same screening before treating:
- Direct inhalation of ozone gas. The fluid lining the lungs has no antioxidants to buffer it, so inhaled ozone is toxic.
- Glucose-6-phosphate dehydrogenase (G6PD) deficiency (favism, acute hemolytic anemia). Madrid lists it as a contraindication for systemic ozone, but whether it is absolute is debated. MediSkill protocols start low and go slow; see the contraindications article.
- Toxic hyperthyroidism (severe Graves' disease)
- Thrombocytopenia (platelets under 50,000) and severe coagulation disorders
- Severe cardiovascular instability
- Acute alcohol intoxication
- Recent acute myocardial infarction
- Acute massive hemorrhage
- Convulsive states
- Hemochromatosis
- Patients receiving intravenous copper or iron therapy
Pregnancy. Madrid advises avoiding ozone therapy in the first trimester (weeks 0 to 13) and reserves its use in pregnancy for specialists in gynecology and obstetrics.
More detail
Glove technique steps (ISCO3 method sheet)
- Have the patient rest their hands on a cushion. Clean the back of the hand with an antiseptic.
- Set the generator to a low concentration, 5 to 8 µg/mL for the first session, and fill a 20 mL ozone-resistant syringe.
- Pinch the skin on the back of the hand between two fingers and insert a 30G, 13 mm needle.
- Infiltrate very slowly, pushing the plunger with the other hand, in the direction of the fingers.
- Finish by massaging the area with ozonated oil (600 peroxide index in the method sheet).
- Repeat twice a week, raising the concentration a little each session, until the pain is gone (about 6 sessions).
Equipment
- Ozone generator with an ozone-resistant gas path (quartz glass, titanium, silicone)
- Medical oxygen tank and regulator
- 20 mL siliconized, ozone-resistant luer-lock syringe
- 30G, 13 mm needles
- Ozonated oil, gloves and antiseptic
What the studies used
Study doses are listed as printed in each paper and are not Madrid dosing.
- In 90 people with low back disorders, subcutaneous ozone (1 mL at 2 µg/mL a point, at paravertebral lines or acupuncture points, every other day for 10 procedures) added to standard care was effective in 69% and 73% vs 49% on standard care alone (p<0.05) (Agasarov 2022).
- In 87 people after lung surgery, 3 to 5 mL at 30 µg/mL injected around each incision once lowered resting pain from 6 to 72 hours, with no difference at 3 months. This is a preprint, not yet peer reviewed (VATS incision trial 2023).
- In one woman with thumb-base arthritis who had failed injections, the glove technique (5 mL at 15 µg/mL at the first session, then 10 mL at 20 µg/mL, weekly for 25 sessions) eased pain after the second session. This is a single case report (García 2026).
Evidence is thin: one randomized trial, one preprint and case reports. We found no trial of the glove technique itself, only the ISCO3 method sheet and case reports.
Learn more
Background, benefits and research on injections: Ozone injections, full article. Larger-volume methods: IV ozone (MaH) protocol pairs with local injections.
Related protocols: PRP and Ozone Injection Protocol, Knee Ozone Injection Protocol, Hip Ozone Injection Protocol.
Other injection protocols
For licensed practitioners. Educational reference only, not medical advice. Follow your scope of practice and local regulations.